The Care Quality Commission: Regulating the quality and safety of health and adult social care - Public Accounts Committee Contents

Conclusions and recommendations

1.  The Department is ultimately responsible for the effective regulation of health and adult social care but has not had a grip on what the Commission has been doing. It is clear that the Commission has been struggling for some time, but only now has the Department started to take action. During the hearing the Department's Accounting Officer set out five areas where she wants to see improvements. The Department should turn these areas into an action plan which sets out in detail exactly what needs to be done to secure the changes required. The Department should report back to us by the end of April 2012 on when we can expect to see progress against each of the five areas.

2.  The Commission has been poorly governed and led. The Commission has failed to strike the right balance between registration and inspection. A Board member, Commission staff and representatives of the health and adult social care sectors have raised serious concerns about the Commission's leadership, governance and culture. The Commission is regarded as overly focused on reputation management and has included gagging clauses in its severance deals with staff. Such clauses discourage people from speaking out and making public information that would help drive improvement and hold the Commission to account. The errors in the Commission's annual report to Parliament also raise questions about the effectiveness of governance and internal control. The Department should carry out a fundamental review of the adequacy of the Commission's current governance and leadership, take action to strengthen these areas and hold the Commission and its senior management to account.

3.  The Commission's role is unclear and it does not measure the quality or impact of its own work. The Commission's objective, as set out in legislation, is to 'protect and promote the health, safety and welfare of people who use health and social care services' but it has not defined what success in delivering this objective would look like. It is unclear to what extent the Commission's role involves improvement beyond the essential basic standards of quality and safety. Although the Commission is a Quality Commission it only measures itself against quantitative, activity-based performance measures, with no measures of quality or impact. The Commission, working with the Department, should set out clearly what it is seeking to achieve and develop measures of quality and impact which can be used to assess its effectiveness.

4.  The information provided to the public on the quality of care is inadequate and does not engender confidence in the care system. The Commission does not collate data on enforcement action, and does not present its assessments in a way that gives the public a clear picture of the state of care available. Residential care homes are no longer awarded star ratings, which previously helped the public to differentiate between providers. The Commission should collect and publish data on enforcement, together with information on the extent to which providers in particular areas are meeting the essential basic standards to allow the public to get a national, regional or local picture of the state of care. In addition, the Department should address the gap left by the removal of star ratings.

5.  The registration of GP practices must involve a meaningful assessment of compliance with the essential standards of quality and safety. The proposed process will involve GP practices declaring areas where they are not compliant, and the Commission told us that it will seek to draw on other sources of information to indicate which practices give rise for concern. We are not convinced that this approach will work in practice, particularly given the number of GP practices to be registered, and the Commission risks becoming simply a postbox. The Commission should review and set out how it will make sure that the assessment of GP practices is meaningful. It should develop clear criteria to use to judge when it needs to undertake further investigations before a practice can be registered.

6.  There are inconsistencies in the judgements of individual inspectors and in the Commission's approach to enforcement. The Commission's own internal auditors found variations in how inspectors assess risk and we received evidence that there is insufficient focus on both the quality and consistency of inspectors' work. In addition, the approach to enforcement is variable, with action more likely to be taken against care homes than hospitals. The Commission should provide training and guidance to inspectors that specifically addresses the risk of inconsistent judgements in inspections and enforcement, and should use performance data to monitor trends and identify areas of concern.

7.  The Commission must strengthen its whistleblowing arrangements. Whistleblowing information from staff and the public should be a key source of intelligence about the quality of care, and the number of whistleblowers has increased dramatically since the Winterbourne View case came to light in May 2011. However, the Commission expects callers to use its general enquiry line, which may discourage whistleblowers and not give them the specialist support they require. The Commission should re-establish a dedicated whistleblowing line, operated by specialist staff, and publicise it widely.

8.  The Commission should not take on the functions of the Human Fertilisation and Embryology Authority at this time. The Department is proposing to transfer to the Commission the functions of other organisations, including the Human Fertilisation and Embryology Authority, which regulates IVF services. In our view, the Commission does not have the capacity to take on oversight of such a complex area, and the change would undermine its ability to focus on the improvements it needs to make in relation to its existing regulatory functions.

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© Parliamentary copyright 2012
Prepared 30 March 2012